In a surprising turn of events, Anthem will not implement a planned new policy to reduce payment for same-day evaluation and management (E/M) services by 25 percent. The policy change was announced in a letter to Jack Resneck, Jr., MD, Chair‐Elect of the Board of Trustees of the American Medical Association, from Anthem Executive Vice President and Chief Clinical Officer, Craig Samitt, MD.
Back in November, Resnick had asked Anthem to halt plans to implement the policy, and apparently a number of meetings have been held between AMA leaders and senior Anthem officials leading up to this latest announcement.
In the letter to Resneck, Samitt wrote that while Anthem still holds that there is a duplication of payment when physicians bill an E/M service and a minor surgical procedure on the same day, the company also “believes making a meaningful impact on rising health care costs requires a different dialogue and engagement between payers and providers.”
The policy, which was set to take effect on March 1, 2018, in Indiana, Kentucky, Missouri, Ohio, Wisconsin, and several other states across the country, would have affected E/M services billed with CPT codes 99201-99215 and modifier -25 when performed on the same day as minor surgeries that are billed with CPT codes 10000-69999 (excluding CPT 36415, 36416, and 69210). E/M services performed in the Emergency Department, which are billed with CPT codes 99281-99285, would not have been affected.
An announcement about the change has been posted to the provider portal on Anthem’s website, and Samitt said Anthem contracted providers would be formally notified.
This reversal of policy follows another Anthem decision to ease up on its denial of payment for “non-emergency” emergency department visits. While the policy holds, Anthem announced earlier in February that it would implement a few “always pay” exceptions for certain circumstances. According to FierceHealthcare’s Leslie Small, “These include when the ER visit was associated with an outpatient or inpatient admission, or when the patient received any kind of surgery or an MRI or CT scan.”
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